Clinical Decision Support for Disseminating and Implementing Patient-Centered Outcomes Research (PCOR) Clinical Evidence

临床决策支持(CDS)系统可以通过最大限度地减少诊断错误来增强诊断过程 以及延误，这是患者安全的主要组成部分。最近的联邦法规，包括保护 《获得医疗保险法案》(PAMA)，鼓励CDS的采用和使用，要求门诊提供者 通过合格的CDS机制咨询基于证据的适当使用标准，以订购某些 高级影像检查(例如，CT、MRI)。通过优化实施，PAMA是一个独特的改进机会 诊断影像护理的质量。然而，如果执行不力，它可能会产生干扰性的电子健康 记录(EHR)工作流程和低价值临床警报，对诊断成像利用率几乎没有影响。 哈佛医学院证据图书馆(HMS-LOE)领导了一个由临床医生和 医疗信息学家代表临床证据并对其进行分级，以努力创建CDS消耗品 知识人工制品，可在HMS Countway医学图书馆公开获得。公共领域资源 的临床证据表示为“如果-然后”形式的临床证据逻辑声明(CELS) 使用牛津循证医学中心开发的证据强度系统进行分级。 HMS-LOE中18%的CEL也完全以标准化的语法和格式表示(例如， 医学术语.临床术语[SNOMED CT]，快速医疗保健互操作资源[fhir] 和临床质量语言[CQL])。CEL是专门为CDS消费品设计的，将极大地 促进文物的展示、公开传播和共享。 在本研究中，我们将：1)评估FHIR、CQL和SNOMED CT的技术能力 以患者为中心的结果研究(PCOR)指南来自HMS-LOE的更高级别的结构化 表现，特别是a)使用乳房MRI(替代或替代乳房X光摄影)来诊断 有乳腺癌史的女性中的第二例乳腺癌，b)使用CT扫描检查肺血栓，以及 (C)对肺栓塞高危人群进行医生教育。此外，我们还将：2)验证PCOR CELS 在我们的医疗保健系统(布里格姆和妇女医院)以结构化的方式表示，以及(3) 将以前开发的CDS人工制品扩展到不同的医疗系统(Covenant Health Inc.)使用一个 不同的电子病历实施和健康信息技术(HIT)平台。透明实施 分级和表示的知识构件将促进广泛的传播和互操作性 各种热门平台、最终用户和工作流程。此外，CDS人工制品的验证和评估， 包括可用性和对临床实践的影响，将促进广泛采用。归根结底， CDS用于诊断成像是为了加强以证据为基础的、有效的护理提供。

Clinical decision support (CDS) systems can enhance the diagnostic process by minimizing diagnostic errors and delays, which are major components of patient safety. Recent federal regulations, including the Protecting Access to Medicare Act (PAMA), encourage CDS adoption and use by requiring that ambulatory providers consult with evidence-based Appropriate Use Criteria through qualified CDS mechanisms for ordering certain advanced imaging exams (e.g., CT, MRI). Optimally implemented, PAMA is a unique opportunity to improve the quality of diagnostic imaging care. However, if poorly executed, it could create interruptive electronic health record (EHR) workflows and low value clinical alerts, with little or no impact on diagnostic imaging utilization. The Harvard Medical School Library of Evidence (HMS-LOE) led a multi-disciplinary team of clinicians and medical informaticists to represent and grade clinical evidence in an effort to create CDS-consumable knowledge artifacts, which are publicly available at the HMS Countway Medical Library. Public domain sources of clinical evidence are represented as a Clinical Evidence Logic Statement (CELS) of “If-Then” form and graded using a system developed by the Oxford Centre for Evidence-Based Medicine for strength of evidence. 18% of the CELS in the HMS-LOE are also fully represented in standardized syntax and formats (e.g., Nomenclature of Medicine-Clinical Terms [SNOMED CT], Fast HealthCare Interoperability Resources [FHIR] and Clinical Quality Language [CQL]). CELS are specifically designed to be CDS-consumable and will greatly facilitate representation and public dissemination and sharing of artifacts. In this study, we will: 1) Assess the technical capability of FHIR, CQL and SNOMED CT to represent three patient-centered outcomes research (PCOR) guidelines from the HMS-LOE in a higher-level, structured representation, specifically a) Using Breast MRI (instead of or in addition to mammography) to diagnose a second breast cancer in women with previous breast cancer, b) Using CT scan for Pulmonary Embolism, and (c) Physician education for those at Risk for Pulmonary Embolism. In addition, we will: 2) Validate PCOR CELS represented in a structured representation at our healthcare system (Brigham and Women’s Hospital), and (3) Scale previously developed CDS artifacts to a different healthcare system (Covenant Health Inc.) with a different EHR implementation and health information technology (HIT) platform. Implementing transparently graded and represented knowledge artifacts will promote widespread dissemination and interoperability across varied HIT platform, end-users and workflows. In addition, validation and evaluation of the CDS artifacts, including usability and impact on clinical practice, will enhance widespread adoption. Ultimately, the goal of CDS for diagnostic imaging is to enhance evidence-based, effective care delivery.